Evidence submitted by the British Society
of Audiology (AUDIO 27)
Whether accurate data on waiting times for audiology
services are available
1. Audiology services provide:
— end-to-end diagnosis and on-going
management for about 24 care pathways: 9[9]
— concerned with hearing and balance,
— for adults and for children.
— diagnostic services for other
care pathways.
2. As part of audiology services hearing
aid services have been equipped with modern audiological equipment
and given funds to provide one of two patient management systems.
3. These systems are used for the whole
variety of audiology services and are capable of recording date
of referral and do record date and time of any significant patient
activity including appointments, assessment and fitting of hearing
aids.
4. However there are no standards for recording
referral or appointment type, no systematic interfaces with NHS
systems and there are no standard reports that can be aggregated
easily.
5. We suggest that, whilst there has been
considerable advance in the last year with the data collections
that the DH has established, there are:
— no "accurate" data
available on all the pathways in audiology;
— no "accurate" data
to enable good strategic planning of services eg differentiation
of new referrals, existing patients, existing patients with urgent
needs; and
— good enough data to show that
hearing services are high volume and have long waits.
Thus the data show that there is a problem but
are difficult to use in a strategic planning sense.
Why audiology services appear to lag behind other
specialties in respect of waiting times and access and how this
can be addressed
6. Access is a major element in quality
service provision and in many respects audiology services occupy
two ends of the spectrum. Newborn hearing screening for instance
has improved access to services and reduced social and ethnic
inequalities in those services. This has done this through specific
commissioning of screening and associated services together with
clear quality standards and a commissioning specification for
PCTs. Clearly this service does not lag behind other comparable
services in the UK or elsewhere. On the other hand cochlear implant
services for the profoundly deaf seem to be far less accessible
and in some cases have associated long waits that clearly lag
those in other specialties.
7. However, in terms of adult hearing aid
services, such simple comparisons are not easy to make. In many
areas of the country reported waiting times are minimal and in
others they are simply staggeringly long. Whether this difference
relates to the extent to which waiting times for existing patients
is variably included in data (by differential referral criteria,
or by judging existing patient assessment as repairs) is unclear.
8. There are four components of access that
need to be considered:
— Hearing impairment (deafness)
is insidious in its effect, on average hearing impaired people
who consult wait 12 years (HTA report, Davis et al in press)
before getting a service but only about one in three receive a
service. So access needs recognition of the problem (often others
recognise before the patient).
— A third of people who present
at GP surgeries with hearing problems are referred for assessment.
There is a need for good referral criteria and clearly GPs are
deterred from referring to a system that has long waits.
— There are many people who have
not formally asked for help who would benefit substantially.
— Many other people who would
benefit from services are not seeking services due to lack of
knowledge or due to the lack of appropriate local services eg
this is particularly the case for those people with moderate to
severe hearing loss who may have been told in the past that "there
is nothing much that we can do for you". Due to lack of formal
recall and review arrangements these people and their GPs do not
know that advances such as DSP hearing aids, implantable devices
and environmental aids may be especially helpful if tailored to
their requirements.
9. Waiting times are long because the demands
on the system are not appropriately understood and taken into
account in commissioning services. This is typically the case
were prevalence of need outstrip demand eg there are at least
4 million adults whose hearing might be cost effectively improved
with hearing aids, 10[10]
but only 1.2 million of these use hearing aids (with about 0.3
million hearing aid users having mild hearing loss outside this
definition), with about 0.75 million seeing their GP and with
0.25 million being assessed and fitted with hearing aids for the
first time each year. Small upward variations in referral could
quickly lead to long waits. The demography of hearing impairment
means that needs will continue to grow quickly at 1% per year
for the next 15 years even with no change in prevalence rate due
to the profile of the baby boomers and longer life expectancy.
In addition to these factors there are two other features that
have added to the demand on the services. These are (1) that Digital
Signal Processing (DSP) hearing aids are providing far better
outcomes and choice for patients than ever before—meaning
that there is greater demand that have grown (2) there has not
been a consistent policy about exchanging current analogue hearing
aids used by patients for the more successful digital hearing
aids. It is clear that this policy is variable and variably applied
across the country leading to shorter or longer waiting lists.
10. There is no doubt that in terms of workflow
that there are not many processes in common across departments
and that skill mix is not deployed to make the best use of audiological
skills. Good practice needs to be applied in terms of waiting
list management and DNAs. Better working practices also need to
be adopted in respect of working with ENT consultants as a diagnostic
service, so that time is used more effectively. These practices
would enable better productivity of staff in hearing aid services.
11. In order to provide better access to
hearing healthcare consideration should be given to providing
a screening, assessment or triage service in primary care. Together
with more local accessible hearing services (that could capitalise
in NHS Direct and NHS Walk in Centres as well as appropriate use
of local authority infrastructure) this would ensure that need
is equally met across the country. In order to ensure that waiting
times are in line with other services, commissioners need to make
robust commissioning arrangements against agreed quality standards
with appropriate monitoring arrangements.
Whether the NHS has the capacity to treat the
numbers of patients waiting
12. If appropriate commissioning and management
arrangements were in place it is probable that the NHS might be
able to assess and treat the numbers of new patients waiting.
13. Under current policies it is unclear
whether existing patient care, hearing aid upgrade and hearing
reassessment could be undertaken with the current capacity.
14. Clearly, there is not enough capacity
to treat those who would benefit from services.
Whether enough new audiologists are being trained
15. The workforce plans for ENT, audio-vestibular
medicine and for audiology show the profiles for each of these
workforces that play an increasingly inter dependent part in audiology
services. The numbers need to be viewed and planned as a whole
for audiology services to benefit the most over the next 10-20
years.
16. Graduate training in audiology in the
UK is in its infancy and the first graduates are just beginning
to take up posts. The indications are that these graduates are
of incredibly high quality and could play a huge part in taking
audiology forward in terms of leadership, scholarship and clinical
practice. Clearly, it would be a big mistake not to train sufficient
graduates of this calibre and deploy them.
17. However, it is clear that despite the
workforce review recommending, for example, employing 200 additional
paediatric audiologists to meet the changing service requirement,
this has not happened, nor have graduates been recruited in the
numbers that were envisaged when graduate courses were set up.
This needs to be tackled. There is an additional requirement for
assistants and associates to enable more efficient and productive
services that are not being provided at the moment.
How great a role the private sector should play
in providing audiology services
18. The private sector provides a good proportion
of hearing aids in the UK to people who pay (about 20% of those
who have aids, about a third of these also have NHS hearing aids).
The private sector has expanded its services in the UK and there
is a reasonable choice of hearing aid on the high street at a
variety of prices. The private sector has also been procured to
provide services (some places this has been additional capacity,
in a few places this has been a replacement) for the NHS. It has
done this with outcomes that are on a par overall the same compared
with the NHS. Local health economies need to decide what sort
of partnership, extent and type, they have with the private sector
and ensure that they specify the services, including maintenance,
training and audit to good quality standards. If the role is not
a quality partnership that is managed then it will not provide
good long term services to hearing impaired patients—most
of whom need about 12 or 15 years of support post assessment.
British Society of Audiology
January 2007
9 See Do Once and Share-Hearing project report on www.mrchear.info Back
10
Davis, A, Smith, P, Ferguson, M, Stephens, D, and Gianopoulos,
Acceptability, benefit and costs of early screening for hearing
disability, HTA 2007 (in press). Back
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